Application: Resident Agent for Tourist Rooming House

Application: Resident Agent for Tourist Lodging Permit

To qualify as a Resident Agent the person must be a natural person residing in or within twenty-five (25) miles of the Village of Lake Delton. Has no pending criminal charges or has been convicted of a felony or misdemeanor of any offense involving dishonesty, fraud, deceit, robbery, the use or threatened use of force or violence upon the person of another, or sexual immorality under Ch. 944, Wisconsin Statutes, as amended.

Applicant name for Resident Agent*

FirstMiddleLast

Resident Agents Address*

Physical AddressMailing AddressCityStateZIP Code

24 hour Contact Phone Number for Agent*

Agent Email*

Property Owner Email*

For Confirmation

Upload Copy of Agent's Driver's License or ID*

Accepted file types: jpg, pdf.

Has the applicant ever been convicted of a felony or misdemeanor of any offense involving dishonesty, fraud, deceit, robbery, the use or threatened use of force or violence upon the person of another, or sexual immorality under Ch. 944, Wisconsin Statutes, as amended?*

If yes, use for other and give law or ordinance violated, trial court, trial date and penalty imposed, and/or date, description and status of charges pending.

NO

Does the applicant have any pending any criminal charges?*

If yes, use for other to describe status of charges pending.

NO

Premise Description*

Physical Address of Rental Property

Total Fee for Resident Agent for Tourist Lodging

$50.00

Due to the Village of Lake Delton by September 1 each year
Send check to Village of Lake Delton c/o TR Housing Renewal P.O. Box 87 Lake Delton WI 53940-0087

Signature*

ACCEPTANCE BY RESIDENT AGENT
I, the above named applicant, hereby accept this appointment as resident agent for the above premise description
owned by rental property and assume full responsibility for the operation of said property and will abide by all of
the State of Wisconsin and Village of Lake Delton rules and regulations.